Preparing the ED for Single Patient Decontamination
September 11th and the subsequent anthrax attacks underscored the need for hospitals to prepare to treat victims of weapons of mass destruction. Joint Commission Emergency Management standards (1) require hospitals to develop plans that provide for chemical, biological, radiological and nuclear (CBRN) decontamination. In addition, the federal government has committed millions of dollars in grants funds to prepare hospitals for patient decontamination and other terrorism related emergencies. To that end, many IHS hospitals have assembled patient decontamination teams and purchased large portable shower tents that can be deployed following a mass casualty event. However, many IHS facilities are located in rural areas where it is just as likely if not more so that a single patient will present contaminated with a hazardous material such as a pesticide from a farm accident. The deployment of a decontamination team and shower tent under the best of circumstances will likely take at least 30 minutes. This poses a question: are IHS hospitals prepared to decontaminate a single patient quickly and effectively? This article explores key facets of single patient decontamination including who will likely be conducting single patient decontamination, maintaining appropriate supplies and equipment, as well as coordinating the proper training.
Elements of a Single Patient Decontamination Plan
Planning for single patient decontamination should include identification of the workers who will be washing the patient, training, location of the decontamination site, source of water, security, medical monitoring of workers, proper clean up, donning and doffing of personal protective equipment (PPE), and more (2).
When presented with a single contaminated patient, time is of the essence, particularly if the patient has injuries. The patient may also present after normal hours. Therefore, Emergency Department (ED) staff will likely have to conduct the patient decontamination. ED personnel should be trained, know the location of the supplies and have appropriate personnel protective equipment on hand.
What equipment is needed?
According to the OSHA publication Best Practices for Hospital-Based First Receivers of Victims from Mass Casualty Incidents Involving the Release of Hazardous Substances, Emergency Departments should have an internal decontamination room to be used for single patient decontamination. The room should be directly vented to the outside with a negative pressure relationship to the rest of the hospital. It should have an active drain valve to divert wastewater into a holding tank and prevent contamination of the community sewer system. The room should be free of non essential and non disposable equipment and should be stocked with necessary items for proper decontamination procedures.
Unfortunately, a dedicated decon room is not always available, especially in older facilities, and the patient will have to be decontaminated outside to prevent entrainment of contaminants in the hospital’s HVAC system. In this case, an outside water source should be accessible with both hot and cold water. A garden hose with a spray nozzle should be available to wash off the patient. The hospital should have a plastic pool to contain the waste water. The location of the decontamination site should consider privacy, and a curtain should be stored along with the pool.
The ED should maintain “decon go kit” containing:
• Powered air-purifying respirator (PAPR)
• HEPA/organic vapor/acid gas cartridges
• Double layer protective gloves
• Chemical resistant suit
• Chemical-protective tape to seal suit
• Chemical-protective boots
• Garden hose with spray nozzle
• Mild soap or shampoo
• Plastic pool
• Scrub pads
• Scissors
• Towels
• Trash bags
• Hospital gown
The “decon go kit” should be located in an area of the ED where it can be easily accessed in a timely manner. If a non ambulatory contaminated patient is presented two stretchers should be provided. One stretcher is to be used during decontamination and the other stretcher is to be used after the patient is decontaminated for transportation. Additional medical supplies may be provided for further care of patient on as needed basis.
What to do when the contaminated patient presents?
If a patient presents to the emergency room and is suspected to be contaminated with a biological, chemical or radiological agent, the following actions need to be taken immediately.
• Direct the patient outdoors or to the facility’s internal decontamination room to prevent
contamination of other patients and the rest of the hospital
• Reassure the patient that help is coming
• Activate your facility’s Decontamination Response Plan and grab the “decon go kit”
• Set up decontamination area at predetermined decontamination site
• Properly don level C PPE
• Assist patient in removing contaminated clothing and secure personal property
• Place clothing items in a trash bag or hazardous waste container
• Wash patient with mild soap or shampoo and water for three to five minutes (patient may
wash themselves)
• Guide or transport patient to medical treatment area
• Decontaminate equipment and dispose of waste properly
• Doff PPE
• Restock “decon go kit” with necessary items
There is a plan, now what?
Successfully donning Level C PPE and washing a contaminated patient entails some know-how. OSHA requires that all personnel who will be performing patient decontamination have a minimum of eight hours of operation level training annually (3). In training, participants learn about the CBRN hazards, proper donning and doffing of PPE, triage, safety and the specific Emergency Decontamination plan for your healthcare facility. Drills can be part of the eight hour required training and should be held at least twice annually to familiarize personnel with working in PPE.
Workers performing patient decontamination should also have a medical evaluation. Tyvek suits and PAPRs get hot quickly. There also may be a need to lift or support the patient. It is better to identify employees with underlying medical conditions in advance than to create an additional casualty during a response.
ED personnel are some of the busiest staff in the hospital. It is therefore advisable to break up training in two-hour blocks throughout the year. In addition offering Continuing Medical Education Units for the training helps out with ED staff career development needs. Providing employee recognition such as Civil Service or Commissioned Corps awards is another way to keep personnel engaged. Lastly, it is important to develop support of hospital leadership.
Conclusion
It makes sense particularly for our rural healthcare facilities to have the capacity to decontaminate the single patient. It is also logical that Emergency Department personnel may be the only staff readily available to decontaminate the single contaminated patient. It is therefore important to properly train and equip ED personnel to meet the needs of the patient safely and effectively. Practice makes perfect, so work patient decontamination into the facility’s training plan.
Reference
1. The Joint Commission. (2011). Hospital Accreditation Standards (EM.02.02.05 EP5)
2. United States Department of Labor, OSHA. (2006). Regulation standards- 29 CFR 1910.120. Retrieved from http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=9765
3. Occupational Safety and Health Administration, (2004). OSHA Best Practices for Hospital-Based First Receivers of Victims from Mass Casualty Incidents Involving the Release of Hazardous Substances
